Fractures of Acetabulum & Pelvis:
Fractures of the pelvis and acetabulum are among the most serious injuries treated by orthopedic surgeons. Often the result of a traumatic incident such as a motor vehicle accident or a bad fall, these fractures require rapid and precise treatment and, in some cases, one or more surgical procedures. People of all ages are vulnerable to these injuries. In addition, some elderly patients with fragile bones due to osteoporosis develop pelvic fractures and fractures of the acetabulum with a lower impact fall.
Radiograph of a normal pelvis the complex nature of these fractures can be better understood by looking at the anatomy that is involved. The pelvis is made up of several bones (ileum, ischium and pubic bones) which create a bony ring, meeting at the pubic symphysis in the front and the sacrum (a bone situated at the lower end of the spine) in the back. Together with a number of ligaments and muscles, the bones of the pelvis support the weight of the upper body and rest on the hip joints. The pelvis protects abdominal organs including the intestines and the bladder, as well as major nerves and blood vessels. Pelvic fractures may occur at any location on the bones depending on the nature of the accident and the areas of impact.
Radiograph of the pelvis demonstrating a fracture of the pubic bonesThe acetabulum refers to the part of the pelvis that meets the upper end of the thighbone (the femoral head) to form the hip joint. In a healthy hip, these two bones fit together like a ball and cup, in which the ball rotates freely in the cup. Cartilage lines the bones where they meet at the joint and there is little friction between the surfaces during movement.
Abstract Operative management of displaced acetabular fractures yields better results than no operative management. Over the past decade, surgical approaches to the acetabulum and the surgical tactic for repair of common fracture patterns have been advanced. Excellent outcomes after repair of these injuries can be achieved. In some cases, as in the elderly, or in those cases in which there is significant destruction of the articular cartilage, primary total hip arthroplasty may provide the best solution. Removal of the femoral head allows for excellent exposure of the acetabulum, making it possible to stabilize most fractures without the need for extensile or intrapelvic approaches.
The surgical technique that has been successfully used calls for gaining primary stability of the acetabular columns by open reduction and internal fixation and then using the acetabular component to replace the articular surface. The columns need not be anatomically reduced. Multiholed acetabular shells can be used as internal fixation devices by placing screws into the columns enhancing the stability of the repair. In older individuals with severe osteoporosis, a typical fracture pattern results in intrapelvic dislocation of the femoral head with a blowout fracture of the anterior column and medial wall. Reinforcement rings with cemented acetabular fixation can be used in these cases. The femoral head can be used as bulk bone graft to replace and reinforce the reconstruction. Techniques common to revision of failed acetabular components are helpful in this setting. The results of reconstruction of severe acetabular fractures with total hip replacement have been reported to be similar to those achieved for reconstruction of osteoarthritis.
Throughout treatment and recovery, doctors and nurses are watchful for the following potential complications:
- Deep Vein Thrombosis and Pulmonary Embolism: Blood clots that may form in the veins of the pelvis, thighs, and/or lower legs and may travel to the lungs.
- Pneumonia: An infection of the lungs that may affect any patient who is confined to bed and cannot expand his or her lungs as fully as they normally do.
- Skin Problems resulting from being in one position for a long period of time.
- Muscle Complications due to inactivity.
- Heterotopic Ossification, a condition in which the body mistakenly forms bone in an area where there is normally muscle; prompt treatment is required to prevent this new bone from interfering with joint movement.
- Damage to the Head of the Femur: if the articular cartilage lining of the joint is affected in an injury to the pelvis, and particularly in fractures of the acetabulum, it's important to keep the surfaces of the joint from rubbing together-and to avoid the risk of future development of arthritis. Preoperatively, traction or a system of ropes, pulleys and weights are used to relieve pressure in the joint. Obviously, surgery with open reduction and internal fixation is performed to realign the joint with enough stability to allow immediate mobilization and hence preserve the smooth lining of cartilage and avoid subsequent arthritis. Avascular Necrosis of the Head of the Femur: Patients with a dislocated hip and/or fracture of the acetabulum may have disrupted blood flow to the head of the femur (the ball in the hip joint). This can result in death and collapse of bone tissue and hip joint arthritis.
- Nutritional Problems: The body requires more protein and calories during healing.
- Constipation resulting from inactivity
- Infection at the site of the injury
Patients who have suffered a traumatic accident or injury may experience psychological distress over changes in their appearance and physical functioning. The shock of becoming an accident victim may also linger. As with a serious illness, the patient may wonder "why me" and be searching for reasons the accident occurred. Difficulty sleeping and coping with the pain associated with recovery are very common. Patients with pre-traumatic depression or experiencing other stressful life events are more prone to experience psychological difficulty connected with their fracture.
In many cases, the passage of time eases these symptoms. At HSS, patients and their families have telephone access to trauma nurses with extensive experience in this field. Often they are able to address the questions and concerns that arise. When necessary, the patient's physician may recommend contact with a social worker or psychologist.
The common complications of surgery for the acetabular fractures are:
- Traction injury to the sciatic nerve
- Wound hematoma
- Wound infection
- Intra articular implants
- Heterotrophic ossification
- Avascular necrosis of head of femur and of fracture fragments
- Protrusio acetabuli
- Early degenerative arthrosis
- Implant loosening